tag:theconversation.com,2011:/id/topics/knee-replacement-12149/articlesKnee replacement – The Conversation2022-11-24T13:52:35Ztag:theconversation.com,2011:article/1944602022-11-24T13:52:35Z2022-11-24T13:52:35ZCheaper, tougher, less toxic: new alloys show promise in developing artificial limbs<figure><img src="https://images.theconversation.com/files/496106/original/file-20221118-26-19nxcy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Knee replacements can ease people's pain - but they are also often prohibitively expensive.</span> <span class="attribution"><span class="source">Dragana Gordic/Shutterstock</span></span></figcaption></figure><p>Titanium is a strong, resilient and relatively light metal. Its properties have also been well studied; scientists know a great deal about it. All of this makes it the ideal base for fashioning artificial limbs – particularly knees and hips – and teeth. It is less likely than other metals to rust and, as research <a href="https://www.sciencedirect.com/science/article/abs/pii/S1044580302003200">has shown</a>, it is more compatible with the human body than, for instance, stainless steels and cobalt based materials. </p>
<p>But there’s a major problem: titanium is not cheap. Precise data is hard to come by, but a <a href="https://hipknee.aahks.org/total-joint-replacement-a-breakdown-of-costs/">conservative average cost</a> of titanium-based prostheses is between US$3,000 and US$10,000. That’s expensive for most people, and prohibitively so for the majority of people in middle- and low-income countries like those in Africa.</p>
<p>Again, data is scarce, but a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535807/">recent study</a> about sub-Saharan Africa (excluding South Africa, which has better facilities for such procedures than most other countries on the continent) found that 606 hip and 763 knee replacements were performed between 2009 and 2018. Many more people in the region likely need replacements but will go without because they simply can’t afford the procedure. And, with the global population of those aged 65 and older <a href="https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Highlights.pdf">rising</a>, the demand for implants is set to increase; this age group <a href="https://josr-online.biomedcentral.com/articles/10.1186/s13018-021-02821-8">is prone</a> to diseases like osteoporosis and osteoarthritis.</p>
<p>That’s why we are working to produce cheaper titanium based materials that can be used to make affordable limbs. In our <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/maco.202213076">latest research</a> my colleagues and I experimented with metallic elements like titanium, aluminium, iron and vanadium to create new alloys. We tested each in a solution that mimics humans’ bodily fluids. </p>
<p>We found that the new alloys showed negligible rust in the solution. The new alloys, which are slightly cheaper than the commercial grade alloy, performed as well as it does – and one alloy even outperformed it. </p>
<h2>Pure titanium vs titanium alloys</h2>
<p>The biggest benefit of titanium for making artificial hips, knees and teeth is that it’s safe for use in the human body because it doesn’t degrade easily when exposed to body fluids. </p>
<p>However, when titanium is used in its pure form, it lacks the necessary strength and wear resistance required to cope with the rigours of human activity. </p>
<p>That’s why other metallic elements are added. Examples include aluminium, vanadium, zirconium, tantalum, niobium, molybdenum and iron. Scientists use these and other elements to create new alloys that are stronger and resistant to wear. </p>
<p>Currently the most utilised alloy in artificial hips and knees is Ti-6Al-4V: 90% titanium, 6% aluminium and 4% vanadium. Though it is effective, it has two major drawbacks. The first is the cost. Vanadium is nearly as expensive as titanium. The second is toxicity: aluminium and vanadium are toxic in large quantities. When the material degrades through corrosion, ions are released into the body and can cause chronic inflammation. These ions have also been <a href="https://www.sciencedirect.com/science/article/pii/S0022283619300270">linked</a> to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986683/">Alzheimer’s disease</a>. </p>
<p>For this study we reduced the amount of aluminium and vanadium that are added to Ti-6Al-4V to make new titanium based materials. We also excluded aluminium and replaced vanadium fully with iron to make another, cheaper, titanium based material. </p>
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<a href="https://theconversation.com/south-africa-is-one-step-closer-to-processed-titanium-alloys-122428">South Africa is one step closer to processed titanium alloys</a>
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<p>Then we investigated whether these new implant materials would degrade quickly when immersed in the human body fluid. We used a solution called Hanks Balanced Salt Solution which contains the main ingredients in the human body fluid. We compared the new titanium materials with the commercial grade Ti-6Al-4V that is commonly used.</p>
<h2>The findings</h2>
<p>Almost all the new alloys performed better than Ti-6Al-4V in the salt solution. Those that fared worse in the solution were still on a par with Ti-6Al-4V. And none of the new alloys degraded more than 0.13 millimetres per year, the maximum permissible degradation rate allowed for implant material.</p>
<p>The alloys without vanadium and aluminium performed well, meaning they are potentially safer than Ti-6Al-4V because they have lower toxicity levels.</p>
<p>And, crucially, the new alloys are cheaper to produce than Ti-6Al-4V. We are not working on the actual manufacturing of artificial limbs – this research focuses on the chemical composition of the alloys. So we can’t say what the ultimate cost-saving would be if these alloys were to be used. But, merely by altering the starting materials as we did, replacing aluminium and vanadium fully or partially with iron, up to 10% cost savings can be achieved.</p>
<h2>A promising step</h2>
<p>From 2030 and beyond, <a href="https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Highlights.pdf">more older adults</a> will reside in developing countries such as those across the African continent. As this population increases, the demand for artificial limbs may also rise. That’s why identifying affordable, safe materials is so important. Our research is a promising step towards meeting that goal.</p><img src="https://counter.theconversation.com/content/194460/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Oluwatosin Bodunrin receives funding from the African Academy of Sciences under the AESA-RISE postdoctoral fellowship program, grant number ARPDF 18-03. </span></em></p>As the world’s population ages, cheap, durable and safe artificial limbs will become ever more important.Michael Oluwatosin Bodunrin, Senior lecturer, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1211722019-08-05T20:01:27Z2019-08-05T20:01:27ZWe can cut private health insurance costs by fixing how we pay for hip replacements and other implants<figure><img src="https://images.theconversation.com/files/286876/original/file-20190805-36395-1jwqjef.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients often have little say about the prostheses they're implanted with.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As we age, we’re more likely to need a prosthesis to help us function like we used to. It may be a hip or knee prosthesis to replace a worn-out joint, a new lens after a cataract has been removed, or a pacemaker or cardiac stent after a heart attack. </p>
<p>Australian <a href="https://www.privatehealthcareaustralia.org.au/wp-content/uploads/PHA-Report-Costing-an-arm-and-a-leg-Oct-2015.pdf">prosthesis prices</a> are high by international standards, and these costs come on top of the surgeon’s fees and the hospital’s charges. </p>
<p>Prostheses accounted for <a href="https://grattan.edu.au/presentations/prosthesis-pricing-needs-fundamental-reform/">more than 10% of the growth</a> in private health insurance costs over the past decade. </p>
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<a href="https://theconversation.com/is-a-5-6-increase-in-private-health-insurance-premiums-justified-55435">Is a 5.6% increase in private health insurance premiums justified?</a>
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<p>Australia’s current approach to paying for prostheses in the private health sector incorporates all the wrong incentives and leads to poor outcomes for patients, health insurance members, and taxpayers.</p>
<p>Grattan Institute has today released a <a href="https://grattan.edu.au/presentations/prosthesis-pricing-needs-fundamental-reform/">proposal</a> for fundamental reform of prosthesis pricing which can help rein in rising private health insurance costs and provide patients with better quality devices at lower costs. </p>
<p>This plan includes setting a benchmark price, factoring quality into the pricing system, and allowing payments to be bundled so patients can avoid unexpected out-of-pocket costs.</p>
<h2>Step 1: set a benchmark price</h2>
<p>Australia’s approach to prosthesis pricing in the private health system is heavy on regulation, exemplified by a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-privatehealth-prostheseslist.htm">1,000-page spreadsheet of regulated prices</a>, which includes more than 10,000 centrally determined prices. It’s reminiscent of Soviet-era central planning at its worst. </p>
<p>Prostheses manufacturers or their Australian agents lodge proposals with a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-about-PLAC">government-appointed committee</a>. The committee evaluates the bid and, if approved, recommends the prosthesis be added to the list and the price private health insurers must pay for it.</p>
<p>One useful, if modest, reform would be to modernise the approach to prosthesis pricing, incorporating innovations from pricing of other medical interventions and treatments.</p>
<p>The Pharmaceutical Benefits Scheme (PBS), which subsidises Australians’ medications, for example, has a system of <a href="https://www.pbs.gov.au/browse/group-premium">Therapeutic Group Premiums</a>. Prices for drugs with a similar therapeutic effect are compared, and where there appears to be no incremental benefit within the therapeutic group, the government price is set at the benchmark for all medications in the group. </p>
<p>Adopting a similar approach would create a benchmark price for hip prostheses, and all other hip prostheses could be priced relative to that benchmark price.</p>
<h2>Step 2: factor in quality</h2>
<p>Another improvement – which could be made immediately – would be to use information about the effectiveness of the prosthesis when setting prices. </p>
<p>Information contained in procedure registries such as the <a href="https://aoanjrr.sahmri.com/documents/10180/576950/Hip%2C%20Knee%20%26%20Shoulder%20Arthroplasty">Australian joint registry</a> could be used to estimate the cost-effectiveness of prostheses over patients’ lifetimes. </p>
<p>All hip prostheses, for example, have a small risk of needing to be replaced after three to five years. But some prostheses have significantly higher rates of needing to be replaced (“revised”) than others. </p>
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Read more:
<a href="https://theconversation.com/what-is-the-medical-technology-association-and-how-does-it-wield-its-power-65786">What is the Medical Technology Association and how does it wield its power?</a>
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<p>Under a “lifetime” pricing approach approach, the price for a prosthesis would take account of the likelihood that a revision might be required. </p>
<p>The cost of a revision, including the cost of the hospital admission, is many times the cost of the initial prosthesis. Incorporating revision risk into initial pricing would start to send signals about the importance of long-term costs. </p>
<p>Interestingly, at least one US hospital group has introduced a <a href="https://www.geisinger.org/patient-care/conditions-treatments-specialty/2019/03/06/21/11/lifetime-hip-and-knee0">lifetime hip and knee guarantee</a>, under which the hospital group bears the full cost of any revision. This is a welcome development as it provides a clear incentive for the hospital to chose the prostheses with the lowest revision rates. </p>
<p>About three-quarters of prostheses orthopaedic surgeons choose to implant in their patients <a href="https://aoanjrr.sahmri.com/documents/10180/397736/Hip%2C%20Knee%20%26%20Shoulder%20Arthroplasty">are not among the top ten options</a>, in terms of quality as measured by revision rates. It’s unlikely those surgeons have fully informed their patients of the choices and risks they’ve imposed on the patients’ behalf. </p>
<p>Surgeons might chose a prosthesis out of habit and may not have checked the average performance of their favoured prosthesis. </p>
<p>Interestingly, there is no evidence that better performing prostheses are more expensive than others.</p>
<h2>Step 3: cut red tape and bundle payments</h2>
<p>A bedrock principle of most markets is that the purchaser expects to accrue utility from their purchase. This is not how prosthesis pricing works. </p>
<p>The surgeon is the one who chooses the prosthesis; in the private market, a private hospital purchases the prosthesis; the private health insurer pays for the prosthesis; but it is the patient who wears the cost of any failure of the prosthesis. </p>
<p>This creates an agency problem and is almost guaranteed to lead to problems.</p>
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Read more:
<a href="https://theconversation.com/waiting-for-better-care-why-australias-hospitals-and-health-care-are-failing-104862">Waiting for better care: why Australia’s hospitals and health care are failing</a>
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<p>Fundamental reform is needed to erase the excessive red tape and regulation of prosthesis pricing. </p>
<p>In the public sector, the government <a href="https://www.sciencedirect.com/science/article/abs/pii/016885109594014Y">pays hospitals for each procedure</a> it performs, based on the patient’s <a href="https://www.sciencedirect.com/science/article/abs/pii/016885109594014Y">diagnosis and the procedure</a> they’re having. </p>
<p>These payments can be bundled together to include the procedure and the device. So the payment for a hip replacement includes a prosthesis. Or the payment for a cataract operation includes lenses. </p>
<p>The same rigour, and the ability to bundle payments, should be applied in the private sector.</p>
<p>This would mean private hospitals would be required to tell patients whether they will be hit with any out-of-pocket costs associated with the prosthesis, and what alternative prostheses might be available which involve no out-of-pocket cost, or which are less likely to require a revision. This will help to drive up quality.</p>
<p>Private hospitals – which purchase the prosthesis – would then have an incentive to ensure their surgeons select better-performing prostheses.</p>
<h2>Or throw the current system in the bin</h2>
<p>Prosthesis pricing in Australia is stuck in an out-dated regulatory approach. It’s not providing best value to taxpayers, health insurance members, or patients. </p>
<p>There are ways to improve the existing regulation, but they should be seen only as patch-ups of a rickety system. </p>
<p>That rickety system deserves to be consigned to the dustbin of history and replaced by a fundamentally different approach to paying for surgical care which bundles prosthesis costs into a single price.</p><img src="https://counter.theconversation.com/content/121172/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p>Health insurance costs are rising and the price of prostheses such as hip replacements are partly to blame. But there is a way to rein in costs – and give patients more choice and better devices.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1106422019-02-05T11:40:31Z2019-02-05T11:40:31ZStem cell treatments for arthritic knees are unproven, expensive and potentially dangerous<figure><img src="https://images.theconversation.com/files/256445/original/file-20190130-108334-eplgb0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An X-ray of both knees reveals a narrow space between joints caused by loss of cartilage. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/osteoarthritis-knee-oa-film-xray-both-320994311?src=Kou3_n7urkrDTi76OUcB0g-1-94">Puwadol Jaturawutthichai/Shutterstock.com</a></span></figcaption></figure><p>Twelve patients who tried injections of stem cells were hospitalized with infections, according to <a href="https://www.nytimes.com/2018/12/20/health/stem-cell-shots-bacteria-fda.html">a report in The New York Times</a> that should cause patients concern. More important is that they should investigate stem cell treatments, for conditions such as cartilage injuries to their joints, before committing to one of these procedures. It’s also a valuable reminder that physicians need to work closely with patients to help them understand their options and which choice may be best for them.</p>
<p>Stem cells are “uncommitted” cells that are, at least theoretically, capable of <a href="https://stemcells.nih.gov/info/basics/1.htm">becoming any type of cell</a> – skin, heart, kidney or even knee cartilage cells. Stem cells can come from fetal tissue, including products of in-vitro fertilization as well as placenta and umbilical cord tissue. They can also come from a patient’s own “hidden” adult stem cells, which are most often harvested from bone marrow and fat. The potential for using these cells in medicine is tremendous; for instance, stem cell transplants are used <a href="https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/stem-cell-transplant/types-of-transplants.html">frequently to treat certain cancers</a>, such as leukemias and blood disorders.</p>
<p>I am a professor of orthopedic surgery at the University of Virginia. I am also a victim of knee <a href="https://www.niams.nih.gov/health-topics/osteoarthritis">osteoarthritis</a> and have gone through knee replacements for both of my knees a little over a year ago. Since then I have made it my mission to educate the public about this condition, and to try to keep the enthusiasm regarding new cutting-edge options in check. That is because I have seen many patients who have paid thousands of dollars for a so-called stem cell treatment only to discover later that they were duped. In most cases fortunately, the only injury was to their wallet.</p>
<p>According to the Arthritis Foundation, <a href="https://www.arthritis.org/about-arthritis/understanding-arthritis/arthritis-statistics-facts.php">at least 31 million Americans</a> are affected with osteoarthritis, the most common type of cartilage wear. A quick web search will confirm just how popular “stem cell treatment” is, and how industry and many institutions offer this option.</p>
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<img alt="" src="https://images.theconversation.com/files/256439/original/file-20190130-108338-1eih5kg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/256439/original/file-20190130-108338-1eih5kg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/256439/original/file-20190130-108338-1eih5kg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/256439/original/file-20190130-108338-1eih5kg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/256439/original/file-20190130-108338-1eih5kg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=526&fit=crop&dpr=1 754w, https://images.theconversation.com/files/256439/original/file-20190130-108338-1eih5kg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=526&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/256439/original/file-20190130-108338-1eih5kg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=526&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The four stages of knee osteoarthritis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/stages-knee-osteoarthritis-oa-224218837?src=Kou3_n7urkrDTi76OUcB0g-1-40">Designua/Shutterstock.com</a></span>
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<h1>The truth about stem cells</h1>
<p>Unfortunately, the excitement about <a href="https://doi.org/10.1007/5584_2018_205">stem cells</a> <a href="https://www.webmd.com/osteoarthritis/news/20170407/stem-cells-for-knees-promising-treatment-or-hoax#1">has outpaced the science</a> in <a href="http://doi.org/10.1007/5584_2018_205">many areas of health care</a>. In addition, due to <a href="http://doi.org/10.1210/er.2008-0031">ethical issues</a> associated with the use of fetal tissue, the U.S. Food and Drug Administration <a href="https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm286155.htm">has severely restricted its use</a>. Adult stem cells have fewer regulatory issues, but the <a href="https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm286155.htm">FDA has prohibited “manipulation,”</a> which includes processing and culturing of these cells. Therefore, obtaining an abundant source of concentrated stem cells can be difficult. </p>
<p><a href="http://doi.org/10.4252/wjsc.v6.i5.629">In orthopedics, researchers have proposed using stem cells</a> for the treatment of joint – cartilage damage. This includes <a href="https://www.niams.nih.gov/health-topics/osteoarthritis">osteoarthritis</a>, the thinning of cartilage that causes bones to rub against one another – similar to a car tire going bald after 50,000 miles. Osteoarthritis is the primary cause of <a href="https://www.niams.nih.gov/health-topics/joint-replacement-surgery">joint replacement surgery</a>, and stem cell injections have been promoted as a potential way to avoid joint replacement by regenerating cartilage. Unfortunately, current technology and regulatory issues make obtaining and concentrating true stem cells a challenge, and encouraging them to become and remain cartilage cells and nothing else is even more difficult. </p>
<p>The problem with stem cells is that these cells can continue to evolve; they may not stop development at the cartilage cell phase. They may continue to differentiate into bone cells. This would make the joint even worse because bone creates a rough surface adjacent to the smooth articular cartilage. Bone is actually the end result of arthritis.</p>
<p>According to the American Association of Hip and Knee Surgeons, there are <a href="https://hipknee.aahks.org/can-stem-cell-therapy-help-my-joint-pain/">no proven uses of pain medications or therapies</a> that can delay or reverse the progressive joint destruction that occurs with osteoarthritis. </p>
<p>Any positive effects of current stem cell treatment are likely not the result of the actual cells themselves but something else.</p>
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<a href="https://images.theconversation.com/files/257077/original/file-20190204-193213-gfk67q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/257077/original/file-20190204-193213-gfk67q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/257077/original/file-20190204-193213-gfk67q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=456&fit=crop&dpr=1 600w, https://images.theconversation.com/files/257077/original/file-20190204-193213-gfk67q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=456&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/257077/original/file-20190204-193213-gfk67q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=456&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/257077/original/file-20190204-193213-gfk67q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=573&fit=crop&dpr=1 754w, https://images.theconversation.com/files/257077/original/file-20190204-193213-gfk67q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=573&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/257077/original/file-20190204-193213-gfk67q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=573&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">This is an example of a total knee replacement.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/total-knee-replacement-surgery-94626556?src=ArVhW9WT7ctYHTgLs6aoOw-1-29">Alila Medical Media/SHutterstock.com</a></span>
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<h2>Alternatives to stem cells</h2>
<p>Separating the hype from the reality about the use of stem cells for cartilage injuries is a reminder that all patients – with advice from their doctors – need a clear picture of the potential benefits and side effects of their treatment options. This includes complications from harvesting bone marrow from the pelvis - which actually only contain less than 0.01 percent stem cells - including fracture and injury to adjacent structures and infection as detailed in The New York Times article. And while harvesting fat may seem even more attractive, the yield of actual stem cells may be even less.</p>
<p>Depending on the cause and severity of their knee pain, for example, patients have treatment options that range from physical therapy to injections of various medications to surgery. All have pros and cons; steroid injections can provide quick but short-lived pain relief, while a knee replacement can provide a permanent solution but also requires months of rehabilitation. Doctors need to help patients make the choice that best fits their particular needs.</p>
<p>So while a quick internet search may find clinics that offer stem cell treatments for cartilage injuries that cost thousands of dollars - and are almost always not covered by insurance - I strongly recommend that consumers remember the concept of “buyer beware” and that medical providers remember the Hippocratic principle: “first do no harm.”</p><img src="https://counter.theconversation.com/content/110642/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Miller is a consultant for Arthrex, a maker of medical implants and receives royalties from Elsevier and Wolters-Kluwer medical publishing companies. </span></em></p>When it comes to seeking out stem cell treatments for joint injuries, buyer beware. These so-called miracle treatments are often scams, so it vital for patients to discuss options with a physician.Mark Miller, Professor of Orthopaedic Surgery, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/933772018-03-20T12:22:03Z2018-03-20T12:22:03ZIf your knee hurts, keep exercising, says expert<figure><img src="https://images.theconversation.com/files/210801/original/file-20180316-104663-17yoko7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/362666585?src=R-3i5sdfLvegquCMQseEcw-1-1&size=medium_jpg">AstroStar/Shutterstock.com</a></span></figcaption></figure><p>If you take up exercise later in life, as a treatment for joint or hip pain, you should expect a <a href="https://www.ncbi.nlm.nih.gov/pubmed/26564575">small, temporary increase in pain</a>. But if you proceed sensibly, you will be rewarded with pain relief <a href="https://www.ncbi.nlm.nih.gov/pubmed/25569281">similar</a> to that of a non-steroidal anti-inflammatory drug, such as ibuprofen, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/24462672">twice</a> that of a non-prescription painkiller, such as paracetamol. In fact, the pain relief from taking up exercise is large enough that many people <a href="https://www.ncbi.nlm.nih.gov/pubmed/26488691">put their knee or hip surgery on hold</a>.</p>
<p>Physical activity is important for good health and is prescribed by doctors to treat a range of diseases, including diabetes and cardiovascular disease. But many people don’t follow this advice because of aching joints and the fear that exercise may harm these joints. </p>
<p>Paradoxically, the last 20 years of research has found that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25569281">exercise is a good pain reliever</a>. Today, <a href="https://www.ncbi.nlm.nih.gov/pubmed/24462672">exercise is recommended</a> worldwide as a treatment for painful joints in middle-aged and older people. However, recommending is one thing. Putting this recommendation into practice is something else altogether. </p>
<p>Most people experience a <a href="https://www.ncbi.nlm.nih.gov/pubmed/26564575">10% pain increase</a> when they start to exercise – some experience more, others less. This is not a warning sign but the body signalling that you are doing something you are not used to. Our bodies, including bone, muscle and cartilage are great at adapting and their <a href="https://www.ncbi.nlm.nih.gov/pubmed/16258919">quality improves</a> when we exercise.</p>
<p>How much pain relief you will get depends on how much exercise you do. In our <a href="https://www.ncbi.nlm.nih.gov/pubmed/28173795">study</a> of 10,000 people with knee and hip <a href="https://www.nhs.uk/conditions/osteoarthritis/">osteoarthritis</a>, we found that people who exercised twice a week for six weeks experienced <a href="https://www.ncbi.nlm.nih.gov/pubmed/28173795">25% pain relief</a>, on average. </p>
<p>Earlier research also shows that people who exercise in groups, supervised by a physiotherapist, experience <a href="https://www.ncbi.nlm.nih.gov/pubmed/25569281">greater pain relief</a> than those who exercise at home, unsupervised. Reasons for this difference may be that we work harder and dare to do more when guided by a physiotherapist with specialist knowledge. </p>
<p>To get the most from exercise, you should feel short of breath, or sweat a little, and increase the level of difficulty of the exercises as your body gets stronger.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Participants in the Danish GLAD study.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Two simple rules</h2>
<p>You can exercise safely by following <a href="https://www.ncbi.nlm.nih.gov/pubmed/20565735">two simple pain rules</a>. One, the pain you experience after exercise should be at a level that is tolerable. And, two, you shouldn’t experience any increase in pain from day to day. </p>
<p>Pain should be assessed daily after exercise on a zero-to-ten scale. On this scale, zero to two is considered “safe”, two to five “acceptable”, and five to ten “avoid”. </p>
<p>Let’s say your usual pain is three, and after exercising you rate it five. That’s fine. If your usual pain is three and after exercising you rate it a seven, you have done too much and should cut back the next time. </p>
<p>If your pain goes up to five after exercising, but the next morning is back at three – your usual morning pain – that’s fine. If your pain goes up to five after exercising, and is still at four or five the next morning (that is, more than your usual morning pain), you have done too much and should cut back. Keep at it, but at a lower level. </p>
<h2>Exercising with arthritis</h2>
<p>Interestingly, our research shows that it is safe to exercise with severe arthritis. When people with severe or bone-on-bone arthritis followed these two simple pain rules, <a href="https://www.ncbi.nlm.nih.gov/pubmed/20565735">95% of all exercise sessions</a> were performed with acceptable pain, and pain was relieved after a few weeks. </p>
<p>In a <a href="https://www.ncbi.nlm.nih.gov/pubmed/26488691">recent study</a>, we enrolled people with mostly severe arthritis who fulfilled all the criteria to have a knee replacement op. All the participants received information on arthritis and its treatments, including self-help advice. They also took part in supervised exercise sessions twice weekly for eight weeks, and saw a dietitian if they were overweight. </p>
<p>Half of the participants were randomised to have their knee replaced. Among those not having their joint replaced immediately, only <a href="https://www.ncbi.nlm.nih.gov/pubmed/26488691">a quarter</a> chose to have their joint replaced within a year. In other words, the pain relief that people experienced as a result of the exercise was enough for three-quarters of the participants to delay surgery for at least a year.</p>
<p>Exercise, especially when supervised, provides effective pain relief, but requires physical effort and sweat. Passive treatments, such as manual therapy, deep tissue massage and muscle stretches, given by a physiotherapist, doesn’t seem to work for people with <a href="https://www.ncbi.nlm.nih.gov/pubmed/24846036">hip</a> or <a href="https://www.ncbi.nlm.nih.gov/pubmed/29307722">knee</a> pain.</p><img src="https://counter.theconversation.com/content/93377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ewa M. Roos receives funding from Swedish Research Council, EU, EIT Health and a number of smaller national funds including the Swedish and Danish Rheumatism Associations, Health Care Regions Skåne and Southern Denmark.</span></em></p>Middle-aged and elderly people taking up exercise shouldn’t be put off by joint pain. It will pass.Ewa M Roos, Professor of Muscle and Joint Health, University of Southern DenmarkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/480792016-01-06T11:07:33Z2016-01-06T11:07:33ZAffordable Care Act’s push to consolidate health care to curb costs may backfire<figure><img src="https://images.theconversation.com/files/106752/original/image-20151220-27880-1gavuh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The good old days.</span> <span class="attribution"><span class="source">House call via www.shutterstock.com</span></span></figcaption></figure><p>In the United States, physicians practice medicine in a variety of settings, ranging from small solo practices to large, multispecialty group practices consisting of hundreds or even thousands of practitioners. </p>
<p>The tradition of the solo practitioner is one that is immediately familiar to most people, in part because this is the typical depiction of physician practice in movies and television shows. </p>
<p>However, this model of practice is falling by the wayside, and physicians are increasingly more likely to practice in the setting of large group practices. In 2008, only 18% of family practice physicians <a href="http://www.nytimes.com/2011/04/23/health/23doctor.html?_r=1">were employed</a> in a solo practice, compared with 44% in 1986. This trend is being further encouraged by the Affordable Care Act on the grounds that larger practices can help curb costs by leading to better outcomes.</p>
<p>But will this physician consolidation actually lead to lower health care costs? The answer to this question has important consequences. Consolidation among physician practices has typically occurred via mergers between large health care systems. </p>
<p><a href="http://www.startribune.com/fairview-weighs-merger-with-university-of-minnesota-doctors/331494721/">Proponents</a> of these mergers typically argue that they benefit patients, in large part because of their ability to reduce costs. </p>
<p>Are these claims too good to be true?</p>
<h2>Benefits of a larger practice</h2>
<p>Larger practices can often <a href="http://anesthesiology.pubs.asahq.org/Article.aspx?articleid=2411187">offer</a> many benefits for the physician, such as administrative support, interaction with colleagues and increased resources for professional development.</p>
<p>In addition, these large practices may benefit patients as well. Sometimes, bigger is indeed better, and large practices may be able to improve patient care and reduce costs by leveraging their size to implement large-scale measures aimed at quality improvement. For example, these groups may be able to more easily employ electronic medical record systems aimed at improving coordination of care, monitoring physician performance and reducing physician errors. </p>
<p>Indeed, these potential benefits form the rationale for many policies aimed at encouraging further consolidation among physicians. </p>
<p>For example, the Affordable Care Act <a href="https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/Aco">encourages</a> physicians to form large, multispecialty groups known as Accountable Care Organizations, in large part because of the belief that these organizations will be able to reduce costs by improving coordination of care. </p>
<p>However, a <a href="https://www.healthlawyers.org/EVENTS/WEBINARS/ROUNDTABLEDISCUSSIONS/2011/Pages/PhysicianPracticeMergers.aspx">key question</a> is whether these potential benefits may be outweighed by the potential disadvantages associated with large practices. Of crucial concern to antitrust authorities is that large practices may leverage their size to negotiate higher payments from insurers (and indirectly, patients), which could actually increase costs. </p>
<p>Simply put, a large practice is on much better ground than a solo practitioner to negotiate higher payments from a health insurers. </p>
<p>In a <a href="http://content.healthaffairs.org/content/34/6/916.abstract">recent paper</a>, we examined whether larger practices were associated with higher payments from private insurers in the case of orthopedic surgery and total knee arthroplasty, also known as “knee replacement.” </p>
<h2>Knee-jerk reaction</h2>
<p>As a first step, we characterized the degree to which the provision of total knee arthroplasties in a given area was dominated by a single orthopedic surgery group or a small number of groups. Total knee arthroplasty is a good surgery to study because it is a commonly performed procedure whose use <a href="http://jama.jamanetwork.com/article.aspx?articleid=1362022">nearly doubled</a> from 1991 to 2010. </p>
<p>We then examined whether insurers paid higher prices for total knee arthroplasty in markets dominated by a single group or a small number of groups. </p>
<p>Of course, markets that are dominated by a small number of groups may be associated with many other factors that could drive higher insurer payments. To address this possibility, rather than comparing prices across markets, our approach examined how changes in market structure were associated with changes in total knee arthroplasty payments within a given market over time. </p>
<p>In other words, our approach followed individual markets and asked how the payments in those markets changed over time as the provision of total knee arthroplasty became more (or less) dominated by a small number of groups. </p>
<h2>Consolidation leads to higher costs</h2>
<p>Overall, our results showed that payments were higher in markets dominated by a small number of groups. </p>
<p>In particular, insurer payments for total knee arthroplasty were 7% higher in the markets where the provision of total knee arthroplasty were most dominated by small number of groups, compared with markets where the provision of total knee arthroplasty was more spread out across groups. </p>
<p>To put this in context, this 7% increase is almost as large as the overall long-term decline in total knee arthroplasty payments we observed during the time period we studied (2001-2010). </p>
<h2>Policy implications</h2>
<p>Our results have several important policy implications. </p>
<p>First, they argue for some skepticism in evaluating the potential benefits of mergers between physician groups, as well as hospitals and health care systems more broadly. </p>
<p>While proponents of these mergers typically cite many of the potential benefits –such as the benefits discussed above – our research also suggests that these potential benefits may be outweighed by the ability of large providers to leverage higher payments from health insurers. </p>
<p>Second, our results suggest that antitrust authorities should closely evaluate whether any potential mergers may result in insurers (and patients) paying higher prices for medical services. For example, antitrust authorities should carefully consider the economic impact of the recently announced <a href="http://www.twincities.com/localnews/ci_28947845/fairview-university-minnesota-physicians-announce-merger">merger</a> between Fairview Health and the University of Minnesota’s health system. </p>
<p>At the end of the day, we are witnessing a large change in the way medical practice is being delivered, as the traditional model of solo practice gives way to a model in which physicians tend to practice in the context of larger organizations. </p>
<p>While the model has the ability to benefit patients and physicians, our study suggests that more work is also needed to understand its potential pitfalls.</p><img src="https://counter.theconversation.com/content/48079/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eric Sun does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An examination of orthopedic surgery and knee replacement showed that higher payments were associated with markets dominated by a few large physician groups.Eric Sun, Instructor of Anesthesiology, Perioperative and Pain Medicine, Stanford UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/482392015-09-29T02:27:34Z2015-09-29T02:27:34ZCostly and harmful: we need to tame the tsunami of too much medicine<figure><img src="https://images.theconversation.com/files/96562/original/image-20150929-30976-vga2ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GPs have increased their test ordering by more than 50%. Imaging for back pain is one of the key culprits.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/white_ribbons/6090449846/">lauren rushing/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>ABC’s Four Corners program on <a href="http://www.abc.net.au/4corners/stories/2015/09/28/4318883.htm">waste in health care</a> didn’t pull any punches. “Many common treatments are often unnecessary, ineffective, or worse still harmful,” said presenter Kerry O’Brien, introducing a special investigation narrated by long-time ABC health reporter Dr Norman Swan. “Waste runs into tens of billions of dollars a year – much of it due to overdiagnosis and the ill-advised treatments that follow.” </p>
<p>For those who missed it, last night’s program focused on several high-cost areas of health care where the evidence suggests that too much medicine is doing us more harm than good: knee pain, back pain, chest pain and PSA (prostate specific antigen) screening for prostate cancer. </p>
<p>The program’s key targets were sophisticated and expensive medical tests – such as <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/ct_scan">computed tomography</a> (CT) scans and magnetic resonance imaging (MRIs) – being ordered in ever greater numbers, often unnecessarily. In the past ten years for example, GPs have increased their test ordering by more than 50%. This equates to around four million extra tests a year. </p>
<p>While it might seem like common sense to want to take a test to see what’s wrong, the problem is that test results can often be misleading and unhelpful – and can start a cascade of further unnecessary tests and treatments. </p>
<h2>‘Fixing’ ageing knees</h2>
<p>Take knee pain, for example. In the Four Corners program, Professor Rachelle Buchbinder explained that if you give MRIs to healthy people who have no knee pain, you will still find “abnormalities” in their MRI results. This is partly because of the normal wear and tear associated with ageing.</p>
<p>“A picture in medicine does not always tell a story – a positive test may not mean a thing,” said Swan. “We’re getting a whole lot of knee scans that we don’t need and which cause us risk and expense.” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Arthroscopies are needlessly performed for osteoarthritis of the knee.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/21072575@N00/3567686583/">Laundry Broad/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>The knee example gets worse. </p>
<p>The unnecessary MRI might show some “abnormality” with the knee which has nothing to do with your pain, but is worrying enough to land you with an orthopedic surgeon who recommends and performs an arthroscopy. </p>
<p>But as Buchbinder pointed out, there is evidence, from the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa013259">New England Journal of Medicine</a> no less, suggesting arthroscopy for osteoarthritis of the knee is no better than sham surgery or placebo. More recent evidence, again from the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1305189">NEJM</a>, suggests arthroscopy to clean up a tear to the meniscus is also no better than sham surgery. </p>
<h2>Too much agreement</h2>
<p>One criticism of the Four Corners program is that almost all the interviewees shared the view Australia is doing too many tests and treatments, and urgently needs to wind them back. We didn’t hear anyone take the view we need <em>more</em> medicine not less. </p>
<p>To counter that criticism, and in defence of the program, one of the important roles of investigative media is sometimes to take a perspective and run an argument. There’s undeniably mounting evidence of <a href="https://theconversation.com/au/topics/overdiagnosis">overuse and overdiagnosis</a>, and the scientific credibility of those interviewed was impeccable. </p>
<p>Take Dr Robyn Ward, a cancer specialist and chair of Australia’s Medical Services Advisory Committee, which uses an evidence-based approach to assess new tests and procedures. “Often the best medicine is no medicine at all, or the best intervention is no intervention at all,” said Ward, who sees Australia’s fee-for-service system, which largely rewards doctors for throughput, as one of the drivers of excess. </p>
<p>Other drivers covered in the program included professional interests, commercial forces, technological change, expanding disease definitions, patient demand and cultural faith in early detection.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Professional interests and expanding disease definition can drive overdiagnosis.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/proimos/6870109454/">Alex Proimos/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Another interviewee was Associate Professor Adam Elshaug, who has produced internationally respected work on what’s called “low-value care”. His landmark article, published in the <a href="https://www.mja.com.au/journal/2012/197/10/over-150-potentially-low-value-health-care-practices-australian-study">Medical Journal of Australia</a> in 2012, listed scores of tests and treatments that are being overused or misused. </p>
<h2>A third of health-care costs squandered</h2>
<p>One of the key claims in the Four Corners program was that almost a third of the money being spent on health care is “squandered”. If you include everything we spend, that’s potentially A$46 billion a year wasted. </p>
<p>While this may well be the case in Australia, it’s perhaps worth pointing out that this estimate arises from studies in the United States. </p>
<p>A key paper in the <a href="http://jama.jamanetwork.com/article.aspx?articleid=1148376">Journal of the American Medical Association</a> in 2012 estimated that total health-care waste in the US – including overtreatment, fraud, administrative complexity and other flaws – accounted for between 20% and 50% of the total cost of health care – with the midpoint estimate being 34%. Hence the one-third figure. </p>
<p>To my knowledge, there are as yet no similarly rigorous estimates of waste in Australian health care. </p>
<h2>Where to from here?</h2>
<p>The federal government is running a major review of all tests and treatments covered by Medicare, with <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/consultation-mbsreviewtaskforce">consultation papers</a> released on the weekend. </p>
<p>According to those documents, a key objective of the review “is to eliminate the funding of low-value or inappropriate health services — that is, treatments, procedures and tests which are of little or no clinical benefit, through overuse or misuse, and which in some cases might actually cause harm to patients”. </p>
<p>Apart from the harms, there is also the tsunami of rapidly rising costs of health care, due in part to ageing, in part to more expensive pills and technology, and in part to overdiagnosis and overtreatment. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Growth in Medicare benefits; 1983–84 to 2014–15.</span>
<span class="attribution"><a class="source" href="http://www.health.gov.au/internet/main/publishing.nsf/Content/922CB2933B0F1645CA257EC1001D5C12/$File/MBS%20Review_Consultation%20paper_Overview_FINAL.pdf">MBS Review Consultation Paper Overview, September 2015</a></span>
</figcaption>
</figure>
<p>The national review is expected to report in coming years – though likely only after complex horse-trading over many of the 5,700 items on the Medicare schedule, as doctors debate exactly what is appropriate and what’s not. </p>
<p>In the meantime the best approach is a healthy scepticism and as many questions to your doctor as you can squeeze in. Do I really need that test or treatment? Do I really need that diagnosis? Where’s the evidence? And, perhaps most importantly, what happens if I do nothing? </p>
<p>Believe it or not, doing nothing is often the best medical care you could get.</p>
<p>Who knows, maybe the tide of too much medicine is turning. But can a tsunami can be tamed?</p><img src="https://counter.theconversation.com/content/48239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Ray Moynihan has received funding from Bond University for studies on overdiagnosis. He has written widely on the problem of too much medicine, is a colleague to several of the program interviewees, and is a co-organizer of the international Preventing Overdiagnosis scientific conferences and the national Preventing Overdiagnosis and Overuse meeting. </span></em></p>The evidence suggests too much medicine is doing us harm, particularly when treating knee pain, back pain, chest pain and screening for prostate cancer.Ray Moynihan, Senior Research Fellow, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/310772014-09-01T14:05:35Z2014-09-01T14:05:35ZUsing computers to read X-rays could cut unnecessary knee replacements<figure><img src="https://images.theconversation.com/files/57860/original/6x9m75d6-1409571076.JPG?ixlib=rb-1.1.0&rect=0%2C435%2C1020%2C720&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">No more knees up for a while.</span> <span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/Orthopedic_surgery#mediaviewer/File:Xraymachine.JPG">Thomas Bjørkan</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Musculoskeletal disorders are the <a href="http://www.who.int/pmnch/media/news/2012/who_burdenofdisease/en/">second leading cause</a> of disability worldwide. They affect joints, ligaments, muscles and nerves as well as the structures that support the limbs, neck and back. </p>
<p>The most prevalent of these disorders is osteoarthritis, a progressive disease that causes a depletion of articular cartilage in the joint, and in the lower body it is most frequent in the knee joint. At its end stage, when there’s no more cartilage left in the joint, one bone rubs against the other and as the disease progresses it causes significant pain and disability, as well as reducing <a href="http://www.ncbi.nlm.nih.gov/pubmed/16285189">quality of life</a>. </p>
<p>Operations to replace the knee joint are usually offered at the end stage. However, a King’s Fund report suggested that the waiting list for this kind of surgery <a href="http://www.bbc.co.uk/news/health-27025189">has been creeping up</a>. In the UK, more than 90,000 knee operations were performed in 2012, <a href="http://www.njrcentre.org.uk/njrcentre/NewsandEvents/NJR10thAnnualReport2013/tabid/330/Default.aspx">a 7% increase</a> compared to 2011. Another forecast suggested that this could rise <a href="http://www.ncbi.nlm.nih.gov/pubmed/17403800">by more than 600% by 2030</a>. In Sweden there was a <a href="http://www.ear.efort.org/registers.aspx">three-fold increase</a> in the number of operations between 1995 and 2000. </p>
<p>Knee replacements can also wear out and the procedure to re-do them, called a revision, is more complex, expensive and carries a higher risk of infection. According to National Joint Registry data, the number of revisions <a href="http://www.njrcentre.org.uk/njrcentre/NewsandEvents/NJR10thAnnualReport2013/tabid/330/Default.aspx">is also increasing</a> – 17% between 2011 and 2012.</p>
<h2>Better diagnostics</h2>
<p>Carrying out more operations to keep up pace with increasing demand may be one solution but another important strategy is to improve diagnosis and reduce the rate of revisions. In <a href="http://dx.doi.org/10.1098/rsif.2014.0303">a new study</a> published in Interface, we identified a technique that could improve the success of knee replacement surgery and prevent unnecessary revisions by using software rather than surgeons to read the X-rays used to measure the progression of the disease.</p>
<p>The region around the knee joint replacement where it meets with the bone shows as a dark space called the radiolucency. Radiolucencies are used by doctors to indicate if a joint replacement has become loose and needs to be revised. We analysed 38 assessments of radiolucency made by six surgeons and compared them to a semi-automated imaging algorithm we had developed.</p>
<p>There was large variation in how the surgeons assessed the X-rays in front of them – less than 10% of the dark areas on the X-ray led to total agreement – but for the automated programme this was 81.6%. If used clinically, this tool would provide a more accurate and reliable means of diagnosing the progression of the disease and limit potentially unnecessary surgical revisions.</p>
<h2>Treatment gap</h2>
<p>We know there is a poor relationship between disease grade and symptoms. Pain and disability are reported at all stages of the disease, but there is a shortage of effective treatments for early to mid-stage knee osteoarthritis. This leaves many people trapped in the “treatment gap”, suffering pain and disability while waiting for their disease to progress to the end-stage so they can have a joint replacement. In that time they are likely to suffer disability and <a href="http://www.ncbi.nlm.nih.gov/pubmed/22262497">potential loss of earnings</a>, in addition to the medical costs. For the EU, a conservative estimate of symptomatic knee osteoarthritis was estimated at more than €500 billion a year.</p>
<p>Population studies <a href="http://www.ncbi.nlm.nih.gov/pubmed/18759314">have shown</a> that the lifetime risk of suffering knee osteoarthritis is as high as 45%; a risk that increases with age, with women being more prone to the disease than men. Prevalence is also increasing, driven by an ageing population and the condition <a href="http://www.ncbi.nlm.nih.gov/pubmed/16051931">also been linked</a> to increases in obesity levels. It <a href="http://www.ncbi.nlm.nih.gov/pubmed/14710506">is estimated</a> that 23% of women aged 45 years or older have symptomatic knee osteoarthritis compared with 14% of men in the same age group.</p>
<p>There <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497711/">is evidence</a> that knee surgery is also increasingly being carried out in younger patients – due in part to factors such as obesity. And it has been well established that joint replacement implants have <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917562/">higher revision rates</a> in younger patients. This of course also increases the chances that they will need a second knee replacement in their lifetime.</p>
<p>The current methods of diagnosis are not effective enough at detecting early stage disease or predictive of who will develop symptoms. There is also a pressing need for therapies that are effective in terms of pain relief and restoring function. Importantly, we also need to understand the reasons for revision.</p><img src="https://counter.theconversation.com/content/31077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richie Gill does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Musculoskeletal disorders are the second leading cause of disability worldwide. They affect joints, ligaments, muscles and nerves as well as the structures that support the limbs, neck and back. The most…Richie Gill, Professor of Healthcare Engineering, University of BathLicensed as Creative Commons – attribution, no derivatives.